Comparison of children and adults in deep brain stimulation for Tourette Syndrome: a large-scale multicenter study of 102 cases with long-term follow-up.

BACKGROUND: Deep brain stimulation (DBS) is a promising therapy for refractory Gilles de la Tourette syndrome (GTS). However, its long-term efficacy, safety, and recommended surgical age remain controversial, requiring evidence to compare different age categories. METHODS: This retrospective cohort study recruited 102 GTS patients who underwent DBS between October 2006 and April 2022 at two national centers. Patients were divided into two age categories: children (aged < 18 years; n = 34) and adults (aged ≥ 18 years; n = 68). The longitudinal outcomes as tic symptoms were assessed by the YGTSS, and the YBOCS, BDI, and GTS-QOL were evaluated for symptoms of obsessive-compulsive disorder (OCD), depression, and quality of life, respectively. RESULTS: Overall, these included patients who finished a median 60-month follow-up, with no significant difference between children and adults (p = 0.44). Overall, the YGTSS total score showed significant postoperative improvements and further improved with time (improved 45.2%, 51.6%, 55.5%, 55.6%, 57.8%, 61.4% after 6, 12, 24, 36, 48, and ≥ 60 months of follow-up compared to baseline, respectively) in all included patients (all p < 0.05). A significantly higher improvement was revealed in children than adults at ≥ 60 months of follow-up in the YGTSS scores (70.1% vs 55.9%, p = 0.043), and the time to achieve 60% improvement was significantly shorter in the children group (median 6 months vs 12 months, p = 0.013). At the last follow-up, the mean improvements were 45.4%, 48.9%, and 55.9% and 40.3%, 45.4%, and 47.9% in YBOCS, BDI, and GTS-QOL scores for children and adults, respectively, which all significantly improved compared to baseline (all p < 0.05) but without significant differences between these two groups (all p > 0.05), and the children group received significantly higher improvement in GTS-QOL scores than adults (55.9% vs. 47.9%, p = 0.049). CONCLUSIONS: DBS showed acceptable long-term efficacy and safety for both children and adults with GTS. Surgeries performed for patients younger than 18 years seemed to show acceptable long-term efficacy and safety and were not associated with increased risks of loss of benefit compared to patients older than 18 at the time of surgery. However, surgeries for children should also be performed cautiously to ensure their refractoriness and safety.

C9ORF78 partially localizes to centromeres and plays a role in chromosome segregation.

C9ORF78 is a poorly characterized protein found in diverse eukaryotes. Previous work indicated overexpression of C9ORF78 in malignant tissues indicating a possible involvement in growth regulatory pathways. Additional studies in fission yeast and humans uncover a potential function in regulating the spliceosome. In studies of GFP-tagged C9ORF78 we observed a dramatic reduction in protein abundance in cells grown to confluence and/or deprived of serum growth factors. Serum stimulation induced synchronous re-expression of the protein in HeLa cells. This effect was also observed with the endogenous protein. Overexpressing either E2F1 or N-Myc resulted in elevated C9ORF78 expression potentially explaining the serum-dependent upregulation of the protein. Immunofluorescence analysis indicates that C9ORF78 localizes to nuclei in interphase but does not appear to concentrate in speckles as would be expected for a splicing protein. Surprisingly, a subpopulation of C9ORF78 co-localizes with ACA, Mad1 and Ndc80 in mitotic cells suggesting that this protein associates with kinetochores or centromeres. Levels of C9ORF78 at the centromere/kinetochore also increased upon activation of the mitotic checkpoint. Furthermore, knocking-down C9ORF78 caused mitotic defects. These studies uncover novel mitotic function and subcellular localization of C9ORF78.

Lessons Learned Serving Pregnant, Postpartum, and Parenting People with Substance Use Disorders in Massachusetts: The Moms Do Care Program.

PURPOSE: The purpose of this paper is to describe the design and implementation of a multidisciplinary, integrated approach to supporting pregnant, postpartum, and parenting people (PPPP) and their families affected by substance use disorders (SUD). DESCRIPTION: Between 2015 and 2022, the Moms Do Care (MDC) Program, sponsored by the Massachusetts Department of Public Health Bureau of Substance Addiction Services, established or expanded 11 co-located medical and behavioral health teams in locations across Massachusetts. These teams provided trauma-informed primary and obstetrical health care, SUD treatment and recovery services, parenting support, and case management for approximately 1048 PPPP with SUD. ASSESSMENT: By enhancing the capacity of medical and behavioral health providers offering integrated care across the perinatal health care continuum, MDC created a network of support for PPPP with SUD. Lessons learned include the need to continually invest in staff training to foster teambuilding and improve integrated service delivery, uplift the peer recovery coach role within the care team, improve engagement with and access to services for communities of color, and conduct evaluation and sustainability planning. CONCLUSION: MDC prioritizes trauma-informed integrated care, peer recovery, and commits to addressing inequities and stigma; thus, this program represents a promising approach to supporting PPPP impacted by SUD. The MDC model is relevant for those working to build multidisciplinary, integrated systems of health care and perinatal SUD services for marginalized populations.

Differences in mother-child and father-child RSA synchrony: Moderation by child self-regulation and dyadic affect.

Parents and preschoolers show respiratory sinus arrhythmia (RSA) synchrony, but it is unclear how child self-regulation and the dyadic affective climate shape RSA synchrony and how synchrony differs for mothers and fathers. We examined child average RSA, externalizing problems, and dyadic positive affect as moderators of the synchrony of dynamic, within-epoch child and parent RSA reactivity during a challenging task. Mothers (N = 82) and fathers (N = 60) oversampled for familial risk participated with their 3-year-olds. For mothers, when children showed either higher externalizing or lower average RSA, negative RSA synchrony was observed as dynamic coupling of maternal RSA augmentation and child RSA withdrawal, suggesting inadequate support of the child during challenge. However, when children showed both higher externalizing and lower average RSA, indicating greater regulatory difficulties overall, positive synchrony was observed as joint RSA withdrawal. The same patterns were found for father-child RSA synchrony but instead with respect to the moderators of higher externalizing and lower dyadic positive affect. Findings suggest moderators of RSA synchrony differ by parent and shared positive affect plays a robust role in fathers' RSA reactivity and synchrony. Mothers may be more attuned to children's regulatory capacities, whereas fathers may be more influenced by the immediate behavioral context.

Parental history of childhood maltreatment and child average RSA shape parent-child RSA synchrony.

We examined whether dynamic parent-child RSA synchrony varied by individual differences in child average RSA and parental history of childhood maltreatment (CM), which has been linked to parental behavioral and physiological dysregulation. We also examined whether RSA synchrony was curvilinear, reflecting homeostatic regulation. Synchrony was defined as the dynamic association between parent and child RSA reactivity (change relative to their own mean) within epoch across a challenging task. Eighty-three mother-preschooler and 61 father-preschooler dyads participated. State-trait modeling showed that RSA synchrony was curvilinear such that significant relations were only found at lower and higher child reactivity. Children's higher task average RSA predicted maternal RSA augmentation and lower task average RSA predicted maternal RSA withdrawal, regardless of whether child reactivity in the moment was low or high, suggesting individual differences in child regulatory capacity were associated with dynamic maternal reactivity. When maternal CM history and child average RSA were both higher, mothers showed RSA augmentation. Father-child synchrony was not moderated by child average RSA but greater paternal CM history predicted fathers' greater RSA withdrawal regardless of whether child RSA reactivity was low or high. Findings offer novel insights into the nature and meaning of RSA synchrony with parents at risk.

Development of a mobile application for acute pain management in U.S. military healthcare.

One of the most significant challenges faced by the U.S. military health system is effective pain management. In resource-denied environments such as En Route Care (ERC), patient care begins with effective acute pain management and is vital to ensure optimal long-term patient outcomes. An electronic, mobile pain management application (app) called the Bee Better app was developed to address the gaps in acute pain management for patients transported throughout the ERC system. The app enables patients to track self-reported acute pain data, provides education and evidenced-based non-pharmacologic interventions during transport. The Delphi method was used as a novel approach to solicit feedback from subject matter experts to systematically enhance the app development process. In its current state, the app tracks patients' reported pain data and information regarding medication intake and provides educational resources about medications and the flight environment. Optimally in the future, the app will deliver real-time therapeutic pain interventions, integrate with the electronic health record and communicate with providers in real-time during care, enabling better patient-centered pain management in the austere ERC environment. Initial usability scores were above industry standards indicating a potential benefit in using a rigorous process for healthcare app development. These mobile apps may enable increased self-management and autonomy in resource-limited environments and optimize outcomes of acute pain management.

Retrospective multi-center study of robotic-assisted cholecystectomy: after-hours surgery and business-hours surgery outcomes.

The effect of robotic-assisted cholecystectomy (RAC), when performed after hours, on perioperative outcomes has not been evaluated against outcomes achieved during normal business hours. Subjects 18-80 years old who underwent da Vinci robotic-assisted cholecystectomy from August 2018 to February 2021 were included. Baseline and 30-day perioperative outcomes were retrospectively and consecutively collected and analyzed. Inverse probability treatment weighting (IPTW) was performed to balance patient characteristics between groups. A weighted comparative analysis was followed. Outcomes from 505 patients (after hours, n = 169; business hours, n = 336) undergoing RAC across 5 U.S. medical institutions were analyzed. The higher rates of acute cholecystitis and gallbladder inflammation, gangrene, and intraoperative abnormalities in the after-hours group were associated with higher rates of urgent cases and longer operative times-but not increased complication rates-compared to the business-hours group. There were no significant differences in rates of intraoperative or postoperative complications, readmissions, or reoperations. Integrated da Vinci Firefly fluorescence imaging system was used extensively, and the critical view of safety was achieved in > 96% of cases in both groups. No conversions occurred in the after-hours group compared to four conversions in the business-hours group (p = 0.0266). After-hours patients had shorter outpatient lengths of stay. No mortalities were reported for either group (p = 0.0139). After-hours RAC with integrated da Vinci Firefly imaging performed by surgeons experienced in RAC is associated with similar or improved outcomes than the same procedures during business hours in terms of complications, conversions, readmissions, reoperations, and length of stay. ClinicalTrials.gov identifier: NCT04551820; August 5, 2020.

Appendicitis mimicry of dolichocolon.

Dolichocolon is an under-reported, under-diagnosed etiology of chronic constipation that is often overlooked as being a primary diagnosis. We present a case of an undiagnosed dolichocolon in a young adult female whose initial presentation was concerning of appendicitis. Eventually, the patient underwent a subtotal colectomy as a definitive treatment for chronic constipation. Dolichocolon is an anatomical variant that can have severe lifelong consequences, such as chronic constipation, which greatly affects a patient's quality of life and overall health if undiagnosed. The purpose of this case report is to raise awareness among the surgical community regarding the significance of early dolichocolon diagnosis, prevent misdiagnosis, and ultimately improve patient outcomes, including reducing complications associated with chronic constipation.

Early Enteral Nutrition in Aeromedically Evacuated Critically Ill/Injured Patients With a Resultant Validation Algorithm for the Theater Validating Flight Surgeon.

INTRODUCTION: Early enteral feeding in critically ill/injured patients promotes gut integrity and immunocompetence and reduces infections and intensive care unit/hospital stays. Aeromedical evacuation (AE) often takes place concurrently. As a result, AE and early enteral feeding should be inseparable. MATERIALS AND METHODS: This retrospective descriptive study employed AE enteral nutrition (EN) data (2007-2019) collected from patients who were U.S. citizens and mechanically ventilated. The dataset was created from the En Route Critical Care, Transportation Command Regulating and Command and Control Evacuation System, and Theater Medical Data Store databases. Comparisons were performed between patients extracted and patients not extracted, patients treated with EN and patients treated without EN, and within the EN group, between AE Fed and AE Withheld. The impact of the nutrition support in the Joint Trauma System Clinical Practice Guidelines (CPG) was assessed using the 'before' and 'after' methodology. RESULTS: An uptick in feeding rates was found after the 2010 CPG, 15% → 17%. With the next two CPG iterations, rates rose significantly, 17% → 48%. Concurrently, AE feeding holds rose significantly, 10% → 24%, later dropping to 17%. In addition, little difference was found between those patients not enterally fed preflight and those enterally fed across collected demographic, mission, and clinical parameters. Likewise, no difference was found between those enterally fed during AE and those withheld. Yet, 83% of the study's patients were not fed, and 18% of those that were fed had feeding withheld for AE. CONCLUSIONS: It appeared that the Clinical Practice Guidelines (CPGs) reinforced the value of feeding, but may well have sensitized to the threat of aspiration. It also appeared that early enteral feeding was underprescribed and AE feeding withholds were overprescribed. Consequently, an algorithm was devised for the Theater Validating Flight Surgeon, bearing in mind relevant preflight/inflight/clinical issues, with prescriptions designed to boost feeding, diminish AE withholding, and minimize complications.

Neurosurgical robots in China: State of the art and future prospect.

Neurosurgical robots have developed for decades and can effectively assist surgeons to carry out a variety of surgical operations, such as biopsy, stereo-electroencephalography (SEEG), deep brain stimulation (DBS), and so forth. In recent years, neurosurgical robots in China have developed rapidly. This article will focus on several key skills in neurosurgical robots, such as medical imaging systems, automatic manipulator, lesion localization techniques, multimodal image fusion technology, registration method, and vascular imaging technology; introduce the clinical application of neurosurgical robots in China, and look forward to the potential improvement points in the future based on our experience and research in the field.

The influence of children's effortful control on parent-child behavioral synchrony.

Child temperament appears to evoke specific parenting behaviors that contribute to child development. However, questions remain about whether individual differences in children's temperamental self-regulation, namely, effortful control (EC), shape moment-to-moment parent-child interaction dynamics. Accordingly, we examined whether differences in children's EC were related to dynamic synchrony of parent and child behaviors during a challenging problem-solving task. We also tested whether these relations varied by parents' expressions of positive and negative behaviors that might differentially support or undermine children's regulatory efforts. State-trait multilevel models demonstrated that parent-child dyads engaged in dynamic, real-time behavioral concordance while parents engaged in positive but not negative behaviors. Further, dynamic concordance during parents' expressions of both positive and negative behaviors was moderated such that dyads with children higher in EC showed greater concordance. Additionally, when child behavior was more negative on average, parent behavior was also more negative on average. Results suggest parents' positive (compared to negative) behaviors are more likely to facilitate real-time synchrony and that children with higher EC may experience or foster greater behavioral synchrony with parents. Discussion centers on the importance of children's individual differences in shaping parent-child synchrony and potential implications for children's developing self-regulation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Understanding How Child Temperament, Negative Parenting, and Dyadic Parent-Child Behavioral Variability Interact to Influence Externalizing Problems.

To better understand the development of externalizing behavior, the current study examines how multiple levels of influence (child temperament, negative parenting, and dyadic interactions) work together to increase externalizing behaviors over time. Negative parenting (NP) and observed dynamic dyadic behavioral variability (DBV) in parent-child interactions (e.g., in discipline and compliance) are characteristic of coercive family processes. The present study first examined latent profiles of temperament in 3-year-olds (N = 150). Four temperament profiles emerged: high reactive, exuberant, low reactive, and inhibited. Temperament profiles were then examined as moderators of the effects of age 3 NP and DBV on child externalizing problems at age 4. Exuberant temperament exacerbated the association between higher levels of NP and DBV and higher levels of child externalizing. Additionally, temperament moderated the combined effects of NP and DBV such that at low and mean levels of NP, children with exuberant temperaments who experienced higher DBV had higher externalizing behaviors, whereas at higher levels of NP, the influence of DBV was no longer significant. Results suggest pathways by which children's experiences of NP and DBV with parents contribute to their greater externalizing problems over time, in the context of the child's unique temperament profile.

A role for deficits in GABAergic neurosteroids and their metabolites with NMDA receptor antagonist activity in the pathophysiology of posttraumatic stress disorder.

Trauma-focused psychotherapies show general efficacy in post-traumatic stress disorder (PTSD), although outcomes vary substantially among individuals with PTSD and many patients do not achieve clinically meaningful symptom improvement. Several factors may contribute to poor treatment response, including genetic or environmental (e.g., stress) effects on neurobiological factors involved in learning and memory processes critical to PTSD recovery. In this review, we discuss the relationship between deficient GABAergic neurosteroid metabolites of progesterone, allopregnanolone (Allo) and pregnanolone (PA), and PTSD symptoms in men and women or PTSD-like behavioral abnormalities observed in male rodent models of PTSD. We also review the role and molecular underpinnings of learning and memory processes relevant to PTSD recovery, including extinction, extinction retention, reconsolidation of reactivated aversive memories and episodic non-aversive memory. We then discuss preclinical and clinical research that supports a role in these learning and memory processes for GABAergic neurosteroids and sulfated metabolites of Allo and PA that allosterically antagonize NMDA receptor function. Studies supporting the possible therapeutic impact of appropriately timed, acutely administered Allo or Allo analogs to facilitate extinction retention and/or block reconsolidation of aversive memories are also reviewed. Finally, we discuss important future directions for research in this area. Examining the varied and composite effects in PTSD of these metabolites of progesterone, as well as neuroactive derivatives of other parent steroids produced in the brain and the periphery, will likely enable a broadening of targets for treatment development. Defining contributions of these neuroactive steroids to common PTSD-comorbid psychiatric and medical conditions, as well as subpopulation-specific underlying dysfunctional physiological processes such as hypothalamic-pituitary-adrenal axis and immune system dysregulation, may also enable development of more effective multisystem precision medicines to prevent and treat the broader, polymorbid sequelae of extreme and chronic stress.

Eye-Tracking Technology to Determine Procedural Proficiency in Ultrasound-Guided Regional Anesthesia.

Background: Eye-tracking measures attention patterns, which may offer insight into evaluating procedural expertise. The purpose of this study was to determine the feasibility of using eye tracking to assess visual fixation patterns when performing an ultrasound-guided regional anesthesia procedure and to assess for differences between experienced, intermediate, and novice practitioners. Methods: Participants performed an ultrasound-guided sciatic nerve block 3 times on a fresh cadaver model while wearing eye-tracking glasses. Gaze fixation and dwell time on each location were compared between participants. Eye-gaze paths were used to derive a measure of entropy, or how often participants switched gaze fixations between locations. Results: Five attending anesthesiologists, 5 third-year anesthesiology residents with prior ultrasound-guided regional anesthesia experience, and 5 medical students completed the study. Individuals with more experience were more likely to successfully perform the sciatic nerve block (5/5 attendings, 5/5 residents, 0/5 students; P = .002) and performed the procedure faster (average: attendings 62.6 seconds, residents 106.4 seconds, students 134.4 seconds; P = .089). Participants were progressively faster with practice (Trial 1: 41.8 seconds, Trial 2: 29.2 seconds, Trial 3: 28.9 seconds; P = .012), and the average number of eye shifts per trial decreased from 10.8 to 6.5 to 6 (P = .010). Attending physicians spent significantly less time fixating on the ultrasound monitor compared to trainees (P = .035). Average visual entropy progressively decreased from Trial 1 to Trial 3 (P = .03) and with greater experience (P = .15). There was a strong correlation between entropy and time on task (r(16) = 0.826, P = .001). Conclusions: Experienced providers make fewer back-and-forth visual fixations, spend less time in the procedure, and demonstrate less entropy during ultrasound-guided regional anesthesia procedures. Mobile eye-tracking has the potential to provide additional objective measures of performance that may help not only determine procedural competence but also distinguish between levels of proficiency.

AIM for Teen Moms: Social Support's Role in Contraception Use Among Young Mothers.

PURPOSE: Rapid repeat pregnancy is associated with negative outcomes for teen mothers and their offspring. Contraceptive use can reduce this risk. We explored the impact of AIM for Teen Moms, a future-oriented behavioral intervention, on emotional and tangible support and the influence of this support on the attitudes, intentions, and past 3-month contraceptive use behaviors. METHOD: Participants were 295 first-time moms (ages 15-19) in Los Angeles County who participated in a randomized control trial intervention to reduce rapid repeat pregnancies. Participants completed surveys at baseline and 36-months. Hypotheses were tested using multivariate and interaction analysis. RESULTS: Teen mothers in treatment group reported more emotional (ß =.13, p < .05) and tangible support (ß =.13, p < .05). Higher tangible support was positively associated with birth control attitudes (ß =.13, p < .05), which, in turn, predicted intention to use birth control (ß =.31, p < .001). Intention to use birth control also predicted higher past 3-month birth control use (ß =.18, p < .01); there was also a direct path from attitude to 3-month birth control use (ß =.35, p < .001). There was no association between emotional support and birth control attitudes, intentions, or behaviors. CONCLUSION: AIM for Teen Mom's effects on contraception use at 36 months was mediated by social support, specifically tangible support, which, in turn, affected birth control attitudes, intentions, and reported birth control use. Interventionists must consider how intervention content can specifically address the building of target support to meet the needs of teen mothers.

Pleiotropic endophenotypic and phenotype effects of GABAergic neurosteroid synthesis deficiency in posttraumatic stress disorder.

PTSD is associated with deficits in synthesis of progesterone metabolites such as allopregnanolone and pregnanolone that potently facilitate gamma-amino-butyric acid (GABA) effects at GABAA receptors. These neurosteroids modulate neuronal firing rate, regional brain connectivity, and activation of amygdala-mediated autonomic nervous system, hypothalamic-pituitary-adrenal axis, and behavioral reactions to unconditioned and conditioned threat. They also play critical roles in learning and memory processes such as extinction and extinction retention and inhibit toll-like receptor activation of intracellular pro-inflammatory pathways. Deficient synthesis of these neurosteroids thus may contribute to individually variable PTSD clinical phenotypes encompassing symptom severity, capacity for PTSD recovery, and vulnerability to common PTSD-comorbidities such as major depression, chronic pain, alcohol and nicotine dependence, cardiovascular disease, metabolic syndrome, reproductive disorders, and autoimmune conditions.

Circulating Trends of Influenza and Other Seasonal Respiratory Viruses among the US Department of Defense Personnel in the United States: Impact of the COVID-19 Pandemic.

The objective of this study was to evaluate the impact of the COVID-19 pandemic on the circulation of influenza and other seasonal respiratory viruses in the United States. All data were obtained from the US Department of Defense Global Respiratory Pathogen Surveillance Program over five consecutive respiratory seasons from 2016-2017 through to 2020-2021. A total of 62,476 specimens were tested for seasonal respiratory viruses. The circulating patterns of seasonal respiratory viruses have been greatly altered during the pandemic. The 2019-2020 influenza season terminated earlier compared to the pre-pandemic seasons, and the 2020-2021 influenza season did not occur. Moreover, weekly test positivity rates dramatically decreased for most of the seasonal respiratory viruses from the start of the pandemic through spring 2021. After the easing of non-pharmaceutical interventions (NPIs), circulations of seasonal coronavirus, parainfluenza, and respiratory syncytial virus have returned since spring 2021. High rhinovirus/enterovirus activity was evident throughout the 2020-2021 respiratory season. The findings suggest a strong association between the remarkably changed activity of seasonal respiratory viruses and the implementation of NPIs during the COVID-19 pandemic. The NPIs may serve as an effective public health tool to reduce transmissions of seasonal respiratory viruses.

Relations between social attention, expressed positive affect and behavioral inhibition during play.

Flexible social attention, including visually attending to social interaction partners, coupled with positive affect may facilitate adaptive social functioning. However, most research assessing social attention relies on static computer-based paradigms, overlooking the dynamics of social interactions and limiting understanding of individual differences in the deployment of naturalistic attention. The current study used mobile eye-tracking to examine relations between social attention, expressed affect, and behavioral inhibition during naturalistic play in young children. Children (N = 28, Mage = 6.12, 46.4% girls, 92.9% White) participated in a 5-min free play with a novel age- and sex-matched peer while mobile eye-tracking data were collected. Interactions were coded for social attention and expressed affect and modeled second-by-second, generating 4,399 observations. Children spent more time dwelling on toys than on peers or anywhere else in the room. Further analyses demonstrated children were almost twice as likely to gaze at their peer when simultaneously self-expressing positive affect. Additionally, children were more than twice as likely and more than three times as likely to self-express positive affect when dwelling on peer or in the presence of peer-expressed positive affect, respectively. Behavioral inhibition was not significantly related to social attention. However, children higher in behavioral inhibition were less likely to self-express positive affect in the presence of peer-expressed positive affect. The current results provide a snapshot of relations between social attention, expressed affect and individual differences during play and provide guidance for future work assessing the roles of social attention and positive affect in facilitating positive social interactions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The dynamics of maternal scaffolding vary by cumulative risk status.

Parental scaffolding, or parenting behaviors that support children's independence and competence, can foster children's self-regulation development. Children facing higher cumulative risk may experience less scaffolding and more directives from parents, but it is unclear how cumulative risk affects the dynamics of parent-child interactions in real time. We examined the role of cumulative risk in mothers' moment-to-moment use of scaffolding and directives in response to preschoolers' off- and on-task behaviors (N = 117). Mothers answered questionnaires about cumulative risk at child age 2.5 years and completed a challenging puzzle task with their preschoolers at age 3 years. Continuous-time multilevel survival analyses revealed differences by cumulative risk in the likelihood of mothers' parenting responses following children's off- and on-task behavioral transitions over the course of the interaction. Specifically, when children went off-task, higher cumulative risk was associated with a lower likelihood of maternal scaffolding, but a comparable likelihood of directives, compared to lower risk mothers. When children got on-task, mothers with higher cumulative risk were less likely to respond with scaffolding and more likely to respond with directives than lower risk mothers. These results suggest that parents at higher risk respond with less scaffolding regardless of child behavior and respond with more directive commands when they may be unnecessary. Findings provide novel, real-time descriptive information about how and when parents experiencing cumulative risk use scaffolding and directive strategies, thus informing microlevel targets for intervention. Implications for the development of self-regulation in children at risk are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Enteral Nutrition in the Deployed Critical Care Ground and Air Transport Environment: A Narrative Review.

INTRODUCTION: Early and adequate administration of enteral nutrition (EN) improves outcomes in critical care patients. However, the environment where Critical Care Air Transport teams provide patient care poses particular challenges to achieving the same standard of nutritional support readily administered in civilian intensive care units. Providing the highest standard of nutritional care in austere military environments remains the goal for all patients despite inherent challenges. Enteral nutrition, specifically, is not currently a standard of practice in-flight because of concerns for microaspiration and the associated risk of developing ventilator-associated pneumonia. Clinical concern for aspiration combines with the lack of an EN pump approved for use through Safe-to-Fly testing to further decrease the likelihood of initiating EN in trauma patients. Early EN significantly reduces morbidity and mortality risks; therefore, the lack of nutritional support is contrary to established standards of care in civilian intensive care units. Hence, this literature review proposes to provide a clearer understanding of current EN practices as well as any associated risks within the En Route Care system. METHOD: A narrative review of literature related to EN in military and civilian flight settings using the PRISMA methodology. RESULTS: A search using the key terms of critical care, air ambulance, EN, nutritional status, and aspiration returned a total of 51,990 articles. A title review followed by a more targeted abstract analysis by the research team generated 39 articles for full-text review. The full-text review then yielded a total of 10 relevant articles for inclusion in the final synthesis table. CONCLUSIONS: Overall, the consensus of the literature supports that early evaluation and initiation of standard EN feeding protocols on the ground and during transport improves patient outcomes and enhances injury recovery. However, additional research will determine the current number of patients fed in-flight along with the actual risks and benefits of EN in this population.